Public hospitals still have lessons to learn after Hong Kong patient deaths
- Incidents at city facilities must be thoroughly investigated and measures to prevent a repetition clearly spelled out and promptly implemented
Considering public hospitals provide healthcare for most Hongkongers, the incidence of serious medical blunders is low. Keeping it low is paramount to confidence in the system.
Incidents involving patient safety are bound to be reported from time to time. They must be thoroughly investigated and measures to prevent a repetition clearly spelled out and promptly implemented.
The latter is especially important when a fatal error is the subject of an inquiry and recommendations are made in an attempt to stop it from happening again.
A case in point may be the death of a 79-year-old man at the Caritas Medical Centre last week after an oxygen cylinder valve was found to have been closed during his transfer from an ophthalmology ward to an intensive care ward. In a similar fatal incident at Queen Elizabeth Hospital in 2018, a patient’s ventilation bag was not hooked up to an oxygen cylinder during his transfer.
An investigation blamed inexperience and a lack of communication between nurses.
In the latest incident, Caritas Medical Centre chief executive Dr Nelson Wat Ming-sun said a patient transfer team of two nurses and an ophthalmologist used a mobile oxygen storage cylinder before switching back to a fixed one in the intensive care unit. The case will be put before an investigation panel and the Coroner’s Court.
Meanwhile at the weekend, Hong Kong Buddhist Hospital called police after staff were unable to revive an 83-year-old male patient found unconscious in a medicine and geriatrics ward with tubing from a blood pressure machine wrapped around his neck.
The discovery came just 15 minutes after staff had inspected the ward and found the man, admitted with renal failure and pneumonia, asleep with nothing amiss. Police are investigating a possible suicide.
The hospital has referred the case to the coroner and, rightly, reviewed the positioning of medical equipment and enhanced inspections.
Probe launched into Hong Kong patient’s death after staff find closed oxygen valve
The patient at the Caritas Medical Centre was admitted for cataract surgery, but transferred to intensive care with stomach pain, falling blood pressure and oxygen saturation. A specialist in critical care medicine, Raymond Lee Wai-chuen, asked whether it was appropriate for staff from the ophthalmology department to transfer an unstable patient when they may not have had the relevant experience or training to do so.
This is one issue that must be fully explored, given that inexperience was found to have been a factor in the death at Queen Elizabeth Hospital five years before. We do not know enough to reach our own conclusions.
However, when it comes to experience and expertise in various forms of patient transfer, pressure on staff resources may well be an issue to be taken into account.
